A 50-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath

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A 50-year-old woman presents to the office with complaints of excessive fatigue and shortness of breath after activity, which is abnormal for her. The woman has a history of congestive heart failure with decreased kidney function within the last year. The woman appears unusually tired and slightly pale. Additional history and examination rules out worsening heart failure, acute illness, and worsening kidney disease. The CBC results indicate hemoglobin is 9.5 g/dL, which is a new finding, and the hematocrit is 29%. Previous hemoglobin levels have been 11 to 13g/dL. The patient’s vital signs are temperature 98.7°F, heart rate 92 bpm, respirations 28 breaths per minute, and blood pressure 138/72. The practitioner suspects the low hemoglobin level is related to the decline in kidney function and begins to address treatment related to the condition. Discuss the following:
1. Which test(s) should be performed to determine whether the anemia is related to chronic disease or iron deficiency, and what would those results show?
2. Should the practitioner consider a blood transfusion for this patient? Explain your answer.
3. Which medication(s) should be considered for this patient?
4. What considerations should the practitioner include in the care of the patient if erythropoietic agents are used for treatment?
5. What follow-up should the practitioner recommend for the patient?

Sample Solution

  1. Diagnostic Tests

To differentiate between chronic disease anemia and iron deficiency anemia, the following tests should be performed:

  • Iron Studies: These include serum iron, total iron-binding capacity (TIBC), transferrin saturation, and ferritin levels.
  • Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP): Elevated levels of these markers can suggest inflammation or infection, which can contribute to anemia in chronic kidney disease.
  • Bone Marrow Biopsy: In some cases, a bone marrow biopsy may be necessary to rule out other causes of anemia, such as bone marrow disorders.

Expected Results:

  • Chronic Disease Anemia: In chronic kidney disease, anemia is often due to decreased erythropoietin production by the kidneys. Iron studies may show normal or elevated levels, while ESR and CRP may be elevated.
  • Iron Deficiency Anemia: In iron deficiency anemia, iron studies will show low levels of serum iron and transferrin saturation, and a high TIBC. Ferritin levels will also be low.
  1. Blood Transfusion

The decision to transfuse blood should be based on the severity of the anemia and the patient’s overall clinical condition. In this case, given the patient’s symptoms of fatigue and shortness of breath, a blood transfusion may be considered to improve oxygen-carrying capacity and alleviate symptoms. However, the risks and benefits of transfusion should be carefully weighed, especially in patients with chronic kidney disease.

  1. Medication Considerations

Several medications can be considered for the treatment of anemia in chronic kidney disease:

  • Erythropoietin: A hormone that stimulates red blood cell production.
  • Iron Supplements: Oral or intravenous iron supplementation may be necessary to correct iron deficiency.
  • Folic Acid and Vitamin B12: Deficiencies of these vitamins can also contribute to anemia and may require supplementation.
  1. Considerations for Erythropoietic Agents

When using erythropoietic agents, several considerations should be included:

  • Target Hemoglobin: The target hemoglobin level should be carefully monitored to avoid excessive erythrocytosis, which can increase the risk of cardiovascular events.
  • Iron Status: Iron deficiency should be corrected before or during erythropoietin therapy.
  • Blood Pressure Control: Erythropoietin can increase blood pressure, so it is important to monitor blood pressure closely and adjust antihypertensive medications as needed.
  1. Follow-Up

The patient should be followed up regularly to monitor their hemoglobin level, kidney function, and overall clinical status. Repeat iron studies may be necessary to assess iron status. The frequency of follow-up visits will depend on the patient’s clinical course and the effectiveness of treatment.

 

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